Factors Influencing Cost-Related Nonadherence to Medication in Older Adults: A Conceptually Based Approach

Although multiple noncost factors likely influence a patient's propensity to forego treatment in the face of cost pressures, little is known about how patients' sociodemographic characteristics, physical and behavioral health comorbidities, and prescription regimens influence cost-related nonadherence (CRN) to medications. We sought to determine both financial and nonfinancial factors associated with CRN in a nationally representative sample of older adults.We used a conceptual model developed by Piette and colleagues that describes financial and nonfinancial factors that could increase someone's risk of CRN, including income, comorbidities, and medication regimen complexity. We used data from the 2004 wave of the Health and Retirement Study and the 2005 HRS Prescription Drug Study to examine the influence of factors within each of these domains on measures of CRN (including not filling, stopping, or skipping doses) in a nationally representative sample of Americans age 65+ in 2005.Of the 3071 respondents who met study criteria, 20% reported some form of CRN in 2005. As in prior studies, indicators of financial stress such as higher out-of-pocket payments for medications and lower net worth were significantly associated with CRN in multivariable analyses. Controlling for these economic pressures, relatively younger respondents (ages 65–74) and depressive symptoms were consistent independent risk factors for CRN.Noncost factors influenced patients' propensity to forego treatment even in the context of cost concerns. Future research encompassing clinician and health system factors should identify additional determinants of CRN beyond patients' cost pressures.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/78680/1/j.1524-4733.2009.00679.x.pd

Establishing an Independent Mobile Health Program for Chronic Disease Self-Management Support in Bolivia

Background: Mobile health (m-health) work in low and middle-income countries (LMICs) mainly consists of pilot programmes with an unclear path to scaling and dissemination. We describe the deployment and testing of an m-health platform for non-communicable disease (NCD) self-management support in Bolivia. Methods: 364 primary care patients in La Paz with diabetes or hypertension completed surveys about their use of mobile phones, health and access to care. 165 of those patients then participated in a 12-week demonstration of automated telephone monitoring and self-management support. Weekly Interactive Voice Response (IVR) calls were made from a platform established at a university in La Paz, under the direction of the regional health ministry. Results: 37% of survey respondents spoke indigenous languages at home, and 38% had six or fewer years of education. 82% had a mobile phone; half (45%) used text messaging with a standard phone, and 9% had a smartphone. Smartphones were least common among patients who were older, spoke indigenous languages, or had less education. IVR programme participants completed 1007 self-management support calls, with an overall response rate of 51%. IVR call completion was lower among older adults, but was not related to patients’ ethnicity, health status or healthcare access. IVR health and self-care reports were consistent with information reported during baseline interviews. Patients’ likelihood of reporting excellent, very good, or good health (versus fair or poor health) via IVR increased during programme participation, and was associated with better medication adherence. Patients completing follow-up interviews were satisfied with the programme, with 19/20 (95%) reporting that they would recommend it to a friend. Conclusions: By collaborating with LMICs, m-health programmes can be transferred from higher-resource centres to LMICs and implemented in ways that improve access to self-management support among people with NCDs

Association between depression and concurrent Type 2 diabetes outcomes varies by diabetes regimen

Aims  Although depression has weak associations with several Type 2 diabetes mellitus (DM) outcomes, it is possible that these associations are concentrated within certain patient subgroups that are more vulnerable to their effects. This study tested the hypothesis that depression is related to glycaemic control and diabetes-related quality of life (DQOL) in patients who are prescribed injected insulin, but not those on oral glucose-lowering agents alone. Methods  Participants (103 on insulin, 155 on oral glucose-lowering agents alone) with Type 2 DM were recruited from a large US healthcare system and underwent assessment of glycaemic control (glycated haemoglobin; HbA 1c ), medication adherence and diabetes self-care behaviours, DQOL and depression (none, mild, moderate/severe). Results  There was a significant regimen × depression interaction on HbA 1c ( P  = 0.002), such that depression was associated with HbA 1c in patients using insulin (β = 0.35, P  < 0.001) but not in patients using oral agents alone (β = –0.08, P  = NS). There was a similar interaction when quality of life was analysed as an outcome ( P  = 0.002). Neither effect was mediated by regimen adherence. Conclusions  The generally weak association between depression and glycaemic control is concentrated among patients who are prescribed insulin. Similarly, the association between depression and illness quality of life is strongest in patients prescribed insulin. Because this is not attributable to depression-related adherence problems, psychophysiological mechanisms unique to this group ought to be carefully investigated. Clinicians might be especially vigilant for depression in Type 2 DM patients who use insulin and consider its potential impact upon their illness course. Diabet. Med. 25, 1324–1329 (2008)Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/73538/1/j.1464-5491.2008.02590.x.pd

Racial Discrimination in Health Care Is Associated with Worse Glycemic Control among Black Men but Not Black Women with Type 2 Diabetes

BackgroundA growing body of research suggests that racial discrimination may affect the health of Black men and Black women differently.AimsThis study examined Black patients with diabetes mellitus (DM) in order to test gender differences in (1) levels of perceived racial discrimination in health care and (2) how perceived discrimination relates to glycemic control.MethodsA total of 163 Black patients with type 2 DM (78 women and 85 men) provided data on demographics (age and gender), socioeconomic status, perceived racial discrimination in health care, self-rated health, and hemoglobin A1c (HbA1c). Data were analyzed using linear regression.ResultsBlack men reported more racial discrimination in health care than Black women. Although racial discrimination in health care was not significantly associated with HbA1c in the pooled sample (b = 0.20, 95% CI = −0.41 −0.80), gender-stratified analysis indicated an association between perceived discrimination and higher HbA1c levels for Black men (b = 0.86, 95% confidence intervals (CI) = 0.01–1.73) but not Black women (b = −0.31, 95% CI = −1.17 to −0.54).ConclusionPerceived racial discrimination in diabetes care may be more salient for glycemic control of Black men than Black women. Scholars and clinicians should take gender into account when considering the impacts of race-related discrimination experiences on health outcomes. Policies should reduce racial discrimination in the health care

Karyology of three evolutionarily hexaploid southern African species of yellowfish, Labeobarbus Rüppel, 1836 (Cyprinidae)

The karyotypes of three species of yellowfish, namely Labeobarbus marequensis (A. Smith, 1841), L. capensis (A. Smith, 1841) and L. polylepis (Boulenger, 1907), were examined by Giemsa staining using an approach improved for the description of high chromosome numbers. In each case, 2n = 150; no heteromorphic chromosomes were detected; chromosomes in all morphological categories ranged smoothly from large to small, with no distinctly large submetacentric pairs; and metacentric chromosomes showed little variation in size. Labeobarbus marequensis had 26 metacentric (m), 44 submetacentric (sm), 42 subtelocentric (st) and 38 acrocentric (a) chromosomes and a fundamental number (FN) of 262; L. capensis had 16 m, 58 sm, 42 st and 34 a chromosomes and FN = 266; and L. polylepis had 18 m, 60 sm, 42 st and 30 a chromosomes and FN = 270. These results, combined with published literature, imply that Labeobarbus Rüppel, 1836 is an evolutionarily hexaploid African lineage and support its removal from synonymy with the evolutionarily tetraploid Asian genus Tor Gray, 1834. A review of fundamental numbers for conspecific Labeobarbus species examined in different studies implicated karyological technique as a confounding factor in assessing details of karyotypes, leading to recommendations for future karyological studies of barbine fishes. Potential synapomorphies are pointed out in karyological characters of species within Labeobarbus

Caring for Patients with Diabetes at Safety Net Hospitals and Health Systems: What the Patients Say about Their Care

In 2002, with support from The Commonwealth Fund, the National Public Health and Hospital Institute (NPHHI) created a consortium of safety net hospital systems to work together to address common concerns regarding the care of patients with diabetes. As part of that project, NPHHI conducted a survey of patients with diabetes who received at least some of their care from four Consortium hospital systems: Cambridge Health Alliance; Community Health Network of San Francisco/San Francisco General Hospital; Cook County Bureau of Health Services; and LSU/Medical Center of Louisiana at New Orleans. Patients were surveyed on multiple domains of care, including overall satisfaction, access to important diabetes-related services, self-management, health status, and communication with their health care providers. This effort, known as the Consortium for Quality Improvement in Safety Net Hospitals and Health Systems, was the first initiative of its kind to bring a group of safety net hospital systems together to examine quality of care provided for diabetes patients. The work of the Consortium underscores the critical role that safety net hospital systems play in delivering high quality diabetes care to a patient population that is primarily low income, ethnically and racially diverse, and that has high rates of literacy problems. The study signals the need for comprehensive programs to support the care of vulnerable patients with chronic conditions and highlights areas for improved communication between providers and patients. Project outcomes can be summarized around several major findings: Although Consortium members care for large numbers of patients with diabetes who are?racially and ethnically diverse, low income or uninsured, and often with limited English?or literacy proficiency, the study found few significant differences among racial groups?regarding assessment of health status and access to care. Despite programs at safety net hospitals to increase access to care for patients, uninsured patients continue to report poorer control of their diabetes and disparities in access to care. Compared with patients with any insurance coverage, fewer uninsured patients reported having a primary care provider and more reported skipping medications due to cost Up to one-third of the patients at Consortium hospital systems reported having languages other than English as their primary language, and one-quarter reported having health literacy problems. Patients commonly reported problems understanding basic instructions involved in diabetes management. Safety net hospital systems are continually challenged to provide culturally and linguistically appropriate services for their diverse populations. Appropriate provider-patient communication becomes a particularly salient issue for patients with chronic illnesses like diabetes that require self-management and understanding of providers\u27 instructions. More research is necessary to understand the cultural and linguistic needs of various patient populations and to design targeted programs that address these needs in the context of comprehensive care management. The NPHHI study revealed the importance of providing comprehensive care that draws on relevant health professionals in the management of chronic illness. Diabetes teams should be expanded to include health care professionals and social workers able to address the variety of factors that affect diabetes care for low-income and minority patients. Much more work is necessary to develop comprehensive, tailored diabetes management programs that take into account literacy, language, and co-morbidities. The study identified several key areas for improvement in care for patients with diabetes in safety net hospitals, specifically around patient-provider communication. In general, survey respondents reported few problems with the care they received and their communication with providers, but not consistently across race and ethnicity. A sizable group of patients (one-quarter or more) reported having difficulty understanding their providers\u27 use of medical terminology, identified a need for improved communication, or noted the providers\u27 failure to take into account the patient\u27s religion or culture. Although patients generally identified few problems with the care they received, a remarkably high proportion of survey respondents indicated they were in fair or poor health and/or had pain that interfered with their ability to exercise. In part, this is a reflection of the experiences of patient populations in safety net hospital systems, who tend to suffer from co-morbidities such as heart disease and depression

Engaging family supporters of adult patients with diabetes to improve clinical and patient-centered outcomes: study protocol for a randomized controlled trial

Abstract Background Most adults with diabetes who are at high risk for complications have family or friends who are involved in their medical and self-care (“family supporters”). These family supporters are an important resource who could be leveraged to improve patients’ engagement in their care and patient health outcomes. However, healthcare teams lack structured and feasible approaches to effectively engage family supporters in patient self-management support. This trial tests a strategy to strengthen the capacity of family supporters to help adults with high-risk diabetes engage in healthcare, successfully enact care plans, and lower risk of diabetes complications. Methods/design We will conduct a randomized trial evaluating the CO-IMPACT (Caring Others Increasing EnageMent in Patient Aligned Care Teams) intervention. Two hunded forty adults with diabetes who are at high risk for diabetes complications due to poor glycemic control or high blood pressure will be randomized, along with a family supporter (living either with the patient or remotely), to CO-IMPACT or enhanced usual primary care for 12 months. CO-IMPACT provides patient-supporter dyads: it provides one coaching session addressing supporter techniques for helping patients with behavior change motivation, action planning, and proactive communication with healthcare providers; biweekly automated phone calls to prompt dyad action on new patient health concerns; phone calls to prompt preparation for patients’ primary care visits; and primary care visit summaries sent to both patient and supporter. Primary outcomes are changes in patient activation, as measured by the Patient Activation Measure-13, and change in 5-year cardiac event risk, as measured by the United Kingdom Prospective Diabetes Study cardiac risk score for people with diabetes. Secondary outcomes include patients’ diabetes self-management behaviors, diabetes distress, and glycemic and blood pressure control. Measures among supporters will include use of effective support techniques, burden, and distress about patient’s diabetes care. Discussion If effective in improving patient activation and diabetes management, CO-IMPACT will provide healthcare teams with evidence-based tools and techniques to engage patients’ available family or friends in supporting patient self-management, even if they live remotely. The core skills addressed by CO-IMPACT can be used by patients and their supporters over time to respond to changing patient health needs and priorities. Trial registration ClinicalTrials.gov, NCT02328326 . Registered on 31 December 2014.https://deepblue.lib.umich.edu/bitstream/2027.42/145179/1/13063_2018_Article_2785.pd

Engaging family supporters of adult patients with diabetes to improve clinical and patient-centered outcomes: study protocol for a randomized controlled trial

Abstract Background Most adults with diabetes who are at high risk for complications have family or friends who are involved in their medical and self-care (“family supporters”). These family supporters are an important resource who could be leveraged to improve patients’ engagement in their care and patient health outcomes. However, healthcare teams lack structured and feasible approaches to effectively engage family supporters in patient self-management support. This trial tests a strategy to strengthen the capacity of family supporters to help adults with high-risk diabetes engage in healthcare, successfully enact care plans, and lower risk of diabetes complications. Methods/design We will conduct a randomized trial evaluating the CO-IMPACT (Caring Others Increasing EnageMent in Patient Aligned Care Teams) intervention. Two hunded forty adults with diabetes who are at high risk for diabetes complications due to poor glycemic control or high blood pressure will be randomized, along with a family supporter (living either with the patient or remotely), to CO-IMPACT or enhanced usual primary care for 12 months. CO-IMPACT provides patient-supporter dyads: it provides one coaching session addressing supporter techniques for helping patients with behavior change motivation, action planning, and proactive communication with healthcare providers; biweekly automated phone calls to prompt dyad action on new patient health concerns; phone calls to prompt preparation for patients’ primary care visits; and primary care visit summaries sent to both patient and supporter. Primary outcomes are changes in patient activation, as measured by the Patient Activation Measure-13, and change in 5-year cardiac event risk, as measured by the United Kingdom Prospective Diabetes Study cardiac risk score for people with diabetes. Secondary outcomes include patients’ diabetes self-management behaviors, diabetes distress, and glycemic and blood pressure control. Measures among supporters will include use of effective support techniques, burden, and distress about patient’s diabetes care. Discussion If effective in improving patient activation and diabetes management, CO-IMPACT will provide healthcare teams with evidence-based tools and techniques to engage patients’ available family or friends in supporting patient self-management, even if they live remotely. The core skills addressed by CO-IMPACT can be used by patients and their supporters over time to respond to changing patient health needs and priorities. Trial registration ClinicalTrials.gov, NCT02328326 . Registered on 31 December 2014.https://deepblue.lib.umich.edu/bitstream/2027.42/145179/1/13063_2018_Article_2785.pd