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Case Studies in Implementation Research: Implementing Health Communication Interventions in Diabetes

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Title: Case Studies in Implementation Research: Implementing Health Communication Interventions in Diabetes


1
Case Studies in Implementation Research Implement
ing Health Communication Interventions in
Diabetes
  • Dean Schillinger, MD Margaret Handley MPH, PhD
  • Professor of Medicine Assistant Prof
    Epidemiology
  • UCSF Center for Vulnerable Populations
  • San Francisco General Hospital

2
Current team (partial list)
  • Margaret Handley MPH PhD
  • Olin Lau NP
  • Alison Lum PharmD
  • Urmimala Sarkar MPH MD
  • Dean Schillinger, MD
  • Catalina Soria
  • Stanley Tan

3
(No Transcript)
4
What is the problem we are trying to address?
  • 1. Diabetes huge public health problem, with
    highest prevalence among those with low
    educational attainment/ethnic minorities
  • 2. Limited literacy common among publicly insured
    and uninsured associated with worse diabetes
    outcomes
  • 3. Public delivery systems/Medi-Cal patients only
    rarely provide tailored self-management support
  • 4. Can we reverse the inverse care law?
  • Availability of good care tends to vary inversely
    with need among the populations served

Schillinger, JAMA 2002 Pt Ed Counsel 2004 Am J
Bioethics 2007
5
Formative Research
6
Literacy is Associated with Glycemic Control,
N408
Adjusted OR2.03, p0.02
Adjusted OR0.57, p0.05
(Tight Control HbA1c?7.2)
(Poor Control HbA1cgt9.5)
Schillinger JAMA 2002
7
Adjusted odds of self-reported diabetes
complications, for patients with inadequate vs.
adequate literacy (N408)
Complication n AOR 95 CI
Retinopathy 111 2.33 (1.19-4.57)
Nephropathy 62 1.71 (0.75-3.90)
Lower Extremity Amputation 27 2.48 (0.74-8.34)
Cerebrovascular Disease 46 2.71 (1.06-6.97)
Ischemic Heart Disease 93 1.73 (0.83-3.60)
Schillinger JAMA 2002
8
How is Literacy Linked to Diabetes Outcomes? 4
hypotheses
  • Confounding
  • Limited literacy ?confounders ? illness
  • Mediation at individual or community
    level Limited literacy ?health mediators
    (behavior and exposure)? illness
  • Reverse Causation/cyclical
  • Illness?limited literacy?worse health trajectory
  • Effect Modification at Health Care System Level
  • Limited literacy ?poor quality of care ? illness
    and premature death/morbidity

Schillinger IOM 2004
9
How Does Limited Literacy Affect (Verbal)
Clinical Interactions?
  • Impedes understanding of technical information
    and explanations of self-care
  • Impairs shared decision-making
  • Speed of dialogue, extent of jargon, lack of
    interactivity determinants of effectiveness of
    communication
  • Impairs medication communication, jeopardizing
    patient safety (medication discordance)
  • Interaction between limited Eng proficiency and
    limited literacy

Fang, Schillinger et al. 2006 JGIM Schillinger et
al. 2004 Pt Ed and Counseling Castro, Schillinger
et al, Am J Health Beh 2007 Schillinger et al.
2003 Arch Int Med Schillinger et al 2004. AHRQ
Advances in Patient Safety
10
Diabetes Patients with Limited Literacy
Experience Poorer Quality Communication, N408
Schillinger Pt Ed Counsel 2004
OR1.9p0.04
OR3.2plt0.01
OR3.3p0.02
OR2.4p0.02
32
33
26
21
20
13
13
13
(Often/Always)
(Often/Always)
(Often/Always)
(Never/Rarely/ Sometimes)
11
Does Screening for Limited HL Affect Physician
or Patient outcomes?
  • Barrier to physician-patient communication
  • Many recommend screening because physicians poor
    at identifying patients
  • Little known about impact on clinical care
    processes or health outcomes
  • Potentially stigmatizing

Seligman, Schillinger JGIM 2004
12
RCT to Evaluate Effect of HL Screening on
  • Physician
  • Management strategies
  • Satisfaction
  • Effectiveness
  • Attitudes
  • Patient
  • Self-efficacy (Patient Enablement Instrument)
  • Attitudes
  • Glycemic control

Seligman, Schillinger JGIM 2004
13
Physician Outcomes
of visits
14
Other Outcomes
  • Physicians
  • 62Overestimated HL of their patient
  • 2 Discussed results of screening
  • 27 Planned to discuss results in future
  • Patients
  • No difference in Self-efficacy or HbA1c
  • 98 reported HL screening potentially useful

15
What Do Physicians Say They Need?
Diabetes Class
Medication Adherence Tools
Communication Training for Patients
More Appropriate Educational Materials
Increased Access to Allied Health Professionals
Improved Labeling of Pill Bottles
16
Implications
  • Merely informing physicians of limited HL
    unlikely to have powerful effect
  • More comprehensive interventions or system-wide
    support for physicians may be more effective

17
Rationale for Interventions
  • 1. Health systems place high literacy and
    language demands on patients (mismatch)
  • 2. Growing body of evidence linking communication
    barriers to outcomes
  • 3. Interactive communication can affect outcomes
  • 4. Little known about the extent to which
    population-based approaches can reach high-risk
    patients
  • 5. Public-sector settings rarely have systematic
    disease programs tailored to vulnerable
    populations

18
Remainder of Talk
  • 1. Review in depth IMPLEMENTATION PROJECT 1
  • (IDEALL Project- UCSF PBRN)
  • 2. Review in depth IMPLEMENTATION PROJECT 2
  • (SMART-STEPS Program SF Health Plan)

19
IDEALL Project Improving Diabetes Efforts
Across Language and Literacy
  • Community Health Network of SF/DPH
  • AHRQ
  • CMWF, TCE, CHCF

20
IDEALL PROJECT
Randomize 339 Patients with HbA1c gt8.0
  • 6-10 Patients
  • Health Educator
  • Primary Care
  • Physician

Usual Care
Monthly Group Medical Visits Clinic
Weekly Interactive Technology
Nurse Care Manager
Cantonese-Speaking Group
English-Speaking Group
Weekly ATSM
Primary Care Physician
Spanish-Speaking Group
Patient
Follow-Up Questionnaires (Patient-Centered
Outcomes, Functional Status, Glycemic Control,
Blood Pressure)
21
Automated Telephone Diabetes Self-Management
(ATSM)
  • Interactive health technology, touch tone
    response
  • Weekly surveillance health education (39
    weeks9 mos)
  • In patients preferred language (English, Spanish
    or Cantonese)
  • Generates weekly reports of out of range
    responses
  • Live phone follow-up through a bilingual nurse
    -gtbehavioral action plans

22
Group Medical Visits (GMVs)
Primary Care Provider Health
Educator Pharmacist
Monthly Group Medical Visits
Cantonese-Speaking Groups
English-Speaking Groups
Spanish-Speaking Groups
  • 6-10 patients in monthly group meetings (9
    months)
  • In patients preferred language ( English,
    Spanish, or Cantonese)
  • Facilitated by a bilingual health educator and a
    primary care provider
  • A pharmacist present at end of each group visit
  • Encourage patients to become active in self-care
    through participatory learning and peer education
    -gtbehavioral action plans

23
Key Findings of IDEALL Program Estimating Public
Health Reach of Programs
  • Composite reach product
  • ATSM GMV
  • Overall 22.1 4.8
  • English 20.0 6.4
  • Chinese 22.0 2.7
  • Spanish 24.3 4.0
  • Adequate Literacy 15.6 7.6
  • Limited Literacy 28.0 3.6

Schillinger, Handley et al.Health Ed and Behavior
2007
24
Results Structure and Process Measures
pre post
Plt.05.
Schillinger, Handley in press Diabetes Care
25
Results Functional Outcomes
Rate ratio 0.5 vs UC, 0.35 vs GMV
OR 0.37 vs UC

pre post
Plt.05
26
Results Physiologic Outcomes
pre post
27
ATSM as Surveillance Tool?
CONSENSUS
AE
No event
PotAE
Classification - Preventability - Primary
Provider Awareness
Medical Record
28
Automated telephony provides safety surveillance
function
Preventability
  • 111 participants, 54 inadequate health literacy
  • 264 events among 93 participants (86)
  • 111 AEs and 153 PotAEs

Sarkar, Handley, Schillinger et al. 2008 JGIM
29
Clinician Survey Findings
  • Responses from 87 of 113 (77) physicians who
    cared for 245 of the 330 (74) patients (mean,
    2.8 per physician).
  • Compared to UC, patients exposed to ATSM were
    perceived as more likely to be activated to
    create and achieve goals for chronic care
    (standardized effect size, ATSM vs. UC, 0.41,
    p0.05).
  • Over half of physicians reported that ATSM helped
    overcome 4 of 5 common barriers to diabetes care
  • Physicians rated quality of care as higher among
    patients exposed to ATSM compared to usual care
    (OR 3.6, p0.003), and compared to GMV (OR 2.2,
    p0.06)
  • The majority felt ATSM should be expanded to more
    patients with diabetes (88)
  • a technology-facilitated SMS model was
    particularly effective for their patients and
    practice settings, suggesting that such programs
    should be disseminated and implemented more
    widely.

Bhandari, Handley Schillinger SGIM 2008
30
Health System Findings Cost-Effectiveness
Health Plans
  • Based on functional improvements, we estimated
    that the cost per QALY for ATSM was
  • gt65,000 for both set-up and ongoing costs
  • gt 32,000 for ongoing costs only
  • Cost effectiveness could be further improved with
    (a) scaling up or (b) metabolic outcomes improved
  • A large majority of CA Medicaid health plans
    reported an interest in employing ATSM-like
    technology

Handley, Schillinger, in press Ann Fam Med
2008 Goldman, Handley, Schillinger et al. Am J
Man Care 2007
31
Key Findings of IDEALL Program
  • Reach significant, especially for lower literacy,
    non-English speaking, Medi-Cal, uninsured.
  • Interactive health technology improves patient
    centered care, health behaviors, functional
    status and promotes safety, due to
  • proactive nature
  • hierarchical logic
  • communication tailoring
  • For physiologic effects to be achieved, need
    medication intensification
  • Health plans and clinicians favorably inclined
  • Probably too difficult for individual clinics to
    implement

32
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33
Current Project (IMPLEMENTATION PROJECT
2) SmartSteps Program
  • Partner with a local Medicaid health plan San
    Francisco Health Plan
  • SFHP care managers will make ATSM response calls
  • Test effectiveness when implemented in
    real-world
  • Compare ATSM-ONLY with ATSM-PLUS (medication
    activation)
  • ATSM-PLUS involves merging pharmacy claims data
    with ATSM data to enable care manager counseling

34
Design and Outcomes
  • Wait List Design, with randomization among
    exposed participants. Total N260
  • Outcomes (wait-list vs. ATSM vs. ATSM-Plus)
  • -communication
  • -behavior
  • -functional status
  • -metabolic indicators
  • -patient safety (prevalence and root causes)

35
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36
SFHP Pre- Enrollment Post Card English
37
Spanish
38
Cantonese
39
SFHP Wallet-Size Card English, Spanish and
Cantonese
40
Care manager field
41
Potential Safety Event
42
Safety event assessment
43
Current Plans and Challenges
  • Delays in implementation, successes in IT
  • Initiate outreach and enrollment 9/08
  • Overcome member inertia/barriers to enrollment
  • Develop MOUs with clinics for enrollment and
    coordination of care
  • Finalize protocols re medication
    intensification/adherence promotion
  • Finalize/shorten pre and post-questionnaires

44
Next Steps?
  • 1. Generate new knowledge regarding how to
    transform clinical and public health practice so
    as to benefit populations with greatest need,
    e.g. limited health literacy
  • 2. Translate results of this research into policy
    and practice in public health and health care
    settings throughout California
  • - Medi-Cal managed care demo project at SFHP
    (underway)
  • - Kaiser Diabetes med intensification (soon to
    be implemented)
  • - Retinopathy screening outreach and education
    (proposed)
  • -Oral health counseling as adjunct to fluoride
    varnish (funded)
  • -Create Statewide ATSM resource (like
    1-800-NO-BUTTS? proposed)
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